Quality in Action

In 1991, Temple nephrologist Donald E. Wesson, MD, showed up at his physician's office in excruciating pain. After an initial exam, the doctor ordered an intravenous pyelogram (IVP), which revealed kidney stones. It was the first time Dr. Wesson was diagnosed with the ailment. "That was a useful use of IVP," the chief academic officer at Baylor Scott & White Health said.

The second time he had the pain, hospital protocols still called for an IVP, even for patients with a history of kidney stones. "My question to my doctor, between my screams, was: How is an IVP going to contribute to my care, when you know and I know I have a history of kidney stones, and that's not likely to be affected by the results of IVP?"

The test also carried some risks with it — some patients are allergic to the dye, for example — and the procedure costs money.

He ultimately convinced his doctor the test wasn't necessary. "Quality care is not necessarily the most care. So in this instance, by not having an IVP done, I got better care because it focused the doctors on what needed to be done; it saved me potential risks; and it saved me and the health care system dollars."

That's the gist of the national Choosing Wisely campaign, which Dr. Wesson leads as chair of its creator, the American Board of Internal Medicine (ABIM) Foundation. The program aims to improve quality and reduce waste by getting physicians and patients talking about medical tests and procedures that may be unnecessary and possibly harmful. (See "Choosing Wisely: More Value, Less Waste, Shared Decision Making," December 2012 Texas Medicine, pages 25-29.)

To date, more than 30 medical specialty societies have joined Choosing Wisely to identify and create lists of the top five tests and procedures they say are overused or inappropriate.

But those lists do little good staying on paper, which is why the Texas Medical Association is helping physicians incorporate the program into daily practice. TMA sees Choosing Wisely as a vehicle for quality improvement and is one of only five state medical associations to win a grant from ABIM to promote the campaign in partnership with the TMA Foundation. Choosing Wisely also could factor into statewide quality improvement initiatives, including those being considered by the Texas Institute of Health Care Quality and Efficiency.

"Choosing Wisely has tremendous potential to align the interests of the patient and the interests of the clinician. These really are things that contribute to unnecessary cost and risks. And [the lists] can serve very nicely as a communication tool to facilitate that conversation between the physician and the patient," said Ronald S. Walters, MD, a Houston oncologist and member of TMA's Council on Health Care Quality.

The TMA House of Delegates voted last year to endorse the program after receiving initial approval from the council and Board of Trustees. A $50,000 grant from ABIM allowed TMA and the TMA Foundation to promote Choosing Wisely to Texas physicians in collaboration with county medical societies, the Texas Osteopathic Medical Association, and state medical specialty societies. The grant runs through March 31, 2015.

Putting Choosing Wisely Into Practice

To help physicians understand and implement the program, TMA created a webpage that contains a suite of Choosing Wisely tools and videos.

Dr. Walters differentiated the program from more formal federal and commercial quality measurement initiatives in that it does not include built-in quality metrics and it does not carry any financial bonuses or punishments. That doesn't mean doctors should not try to find gaps in care and track their progress; it does mean Choosing Wisely is fairly simple to put into practice.

"These are just things we should not be doing," he said. "The goal is not measurement. The goal is participation. And there is still a role for awareness and practice change. This is very much about patient safety."

Another "beauty" of the program, he says, is that the lists are evidence-based guidelines vetted and developed by physicians. Individual specialty societies developed the recommendations using the most current evidence about management and treatment options within their specialty. The lists run the gamut, but are generally described as "things whose necessity should be questioned and discussed" between physicians and patients and include indications or flags for when something may be appropriate.

"If you have already embedded evidence-based guidelines into your daily routines, then you are already abiding by many of the principles of Choosing Wisely," said Dr. Walters, a member of the National Quality Forum's measures review committee. But wide variations in practice among physicians in different communities suggests the campaign "still has very real gains it can achieve."

He pointed to prostate-specific antigen (PSA) tests as an example. The Choosing Wisely guidelines from the American Society of Clinical Oncology say: "Don't perform PSA testing for prostate cancer screening in men with no symptoms of the disease when they are expected to live [fewer] than 10 years." But Dr. Walters says there is still "extreme variation" in how and when PSAs are used among patients with a short life expectancy.

Physician leaders say the Choosing Wisely guidelines were developed, in part, by each specialty to reflect those areas where there is variation in physician practice and to help close the gaps. When it comes to putting Choosing Wisely into practice, physicians' own specialty society recommendations are a good place to start.

When Baylor Scott & White adopted the program, rather than designing a separate educational track from scratch, Dr. Wesson and other physician leaders took advantage of the Choosing Wisely lists and materials. "We made that information directly available to our physicians and began by encouraging them to access the information that their own societies are providing to them."

Because most medical care these days is delivered by a health care team, step two was getting other health care professionals such as physician assistants and nurses educated on Choosing Wisely. "That's where we are now in galvanizing all of the providers as to the importance of it and why we are doing it," he added.

Baylor Scott & White is now working on the third — and perhaps more challenging — step: hardwiring the Choosing Wisely recommendations into physicians' daily routines by incorporating them into an electronic medical record (EMR) system. That means creating certain prompts, for example, that explain the indications for a particular test and require physicians to enter a reason before ordering it.

Dr. Wesson acknowledges this phase of implementing Choosing Wisely could pose some obstacles for practices, and the campaign is working to devise the easiest and most practical way for physicians to incorporate it into daily practice. But the obstacles are not insurmountable, he says. Most, if not all, EMRs should allow practices to add on functions like those he describes, though not without some expense. And while using an EMR to implement Choosing Wisely is the best way to go, other options exist; they just require more self-discipline.

Baylor Scott and White adopted Choosing Wisely about a year ago and used handwritten protocols at first.

"It can be done. I have to take medicines for my kidney stones, and I use my watch or alarm clock or computer to set reminders. But without those, I have to rely on myself to do it," Dr. Wesson said. Similarly, "I can do [Choosing Wisely] in handwritten protocols [that remind] providers to get it done, and it works reasonably well. But it works much better if I have structural reminders that make it more of a routine. Having an EMR allows you to do this with less thinking because when you are engaged in a patient encounter, it provides the structural assist."

Realizing the process can get unwieldy as specialty societies continue to join the campaign or add to their "not-to-do" lists, the Choosing Wisely campaign also is working to simplify the program, Dr. Wesson adds. "After a while, these lists could end up with 200 to 300 things, and that can be complicated. So we are trying to come up with a conceptual message clinicians can use versus a specific list of things to do, like: Am I doing this because it's a part of a protocol, or because in this instance, it's going to give me information that will help me with this patient?"

Contributing Value to Patient Care

However physicians choose to start, the most important step is identifying gaps in care so physicians know where to improve, says Garland family physician Cliff Fullerton, MD, chief medical officer of the Baylor Quality Alliance and a member of TMA's Health Care Quality Council. Making those improvements may not be easy at first, he cautions, but they are worthwhile.

"There isn't a financial positive to quit doing some of these things. And it does cost doctors time to talk to patients instead of sending them out the door with an antibiotic," he said. The latter also could negatively impact patient satisfaction rates in the short term if they don't get the drug or test they think they need. "But it's hard to justify saving money or saving time for yourself at the expense of your patients. By engaging in these activities, you are creating a safer environment for your patients."

That will pay off in the long run, he says, especially as commercial and state quality initiatives put more emphasis on value-based care. "The better we [physicians] do, the more appealing we are to payers and employers. And somewhere down the road, patients are going to look at our quality and cost of care. So we want to be doing well when that time comes."

Already, the Texas Institute of Health Care Quality and Efficiency is considering Choosing Wisely as a possible recommendation to the Texas Legislature for advancing the state's version of health care reform passed in 2011. Gov. Rick Perry appointed the institute members in 2012 to "improve health care quality, accountability, education, and cost containment in this state."

Choosing Wisely dovetails with one of the key values the institute is charged with upholding, which is making sure state quality initiatives are evidence-based, says Wichita Falls pathologist Susan M. Strate, MD. She is vice speaker of the TMA House of Delegates and a former member of the TMA Council on Health Care Quality. She also serves on the institute's board of directors.

"An important aspect of Choosing Wisely is the fact that it's been vetted and developed by physicians, and such a program is a very good thing for the institute to consider," she said. In addition, the institute workgroup studying this program is focusing on best practices and patient engagement as two of its main charges, also important aspects of Choosing Wisely.

It may not be a formal value-based care program, Dr. Strate says. But it can help get doctors and patients ahead of the game. "This is about beginning a culture change and helping physicians and patients discuss the value of various health care services when making health care decisions."

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.